Original research A first city-wide early defibrillation project in a German city: 5-year results of the Bochum against sudden cardiac arrest study Christoph Hanefeld Abstract Backgroun
Trang 1Open Access
O R I G I N A L R E S E A R C H
© 2010 Hanefeld; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons At-tribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, disAt-tribution, and reproduction in any medium, provided the original work is properly cited.
Original research
A first city-wide early defibrillation project in a
German city: 5-year results of the Bochum against sudden cardiac arrest study
Christoph Hanefeld
Abstract
Background: Immediate defibrillation is the decisive determinant of prognosis in patients suffering from cardiac/
circulatory arrest caused by ventricular fibrillation (VF) Therefore, various national and international associations recommend that first responders use defibrillators as soon as possible and also recommend public access to early defibrillation programmes Here we report the results of the first city-wide early defibrillation project in a large German urban area
Methods: There were 155 automated external defibrillators (AEDs) put into operation in the Bochum municipal area,
and 6,294 people took part in cardiopulmonary resuscitation (CPR) and AED training Free, accessible AEDs were installed in places with large volumes of people Additionally, emergency forces were progressively equipped with AEDs
Results: Twelve AED administrations prior to the arrival of an emergency physician were recorded and analysed over a
period of 5 years (08/2004-08/2009) Rhythm analysis via AED demonstrated VF in seven cases, non-malignant
dysrhythmias in four cases and asystole in one case Two of the seven patients with VF were successfully defibrillated and survived cardiac/circulatory arrest without any neurological sequelae Eight of the 12 AED applications were performed by laymen The mean time between switching the unit on and applying the electrodes to the patient was
39 seconds (SD +/-20 sec) On average, another 20 seconds elapsed before the AED recommendation of "shock delivery" was displayed, and a total of 96 seconds elapsed before shock administration (± 56 sec)
Conclusion: Consistent with other reports, our findings show that the organisation of a city-wide initiative by a project
office combining public access and first-responder defibrillation programmes can be safe, feasible and successful Our experiences confirm that strategic planning of AED placement is a prerequisite for successful, cost-effective
resuscitation
Introduction
Cardiovascular disease is the most common cause of
death in individuals over the age of 40 years [1] In the
US, approximately 250,000 individuals die from cardiac/
circulatory arrest annually, and the most common
dys-rhythmia is ventricular fibrillation VF [2] In Europe, the
overall incidence for all-rhythm arrests is estimated as
37.72 per 100,000 person-years [3] Notably, less than 5%
of patients survive an out-of hospital cardiac/circulatory
arrest [4] Different approaches have been pursued in the
past to train the population in recognising cardiac/circu-latory arrest and applying basic CPR measures; attempts have also been made to improve emergency medical ser-vices (EMS) care [5]
The decisive determinant of prognosis in patients suf-fering from cardiac/circulatory arrest caused by VF is immediate defibrillation The chance of survival in these patients depends directly on the time elapsed between cardiac/circulatory arrest and defibrillation [6-8] There-fore, different national and international associations rec-ommend that first responders use defibrillators as soon
as possible, and they recommend public access to early defibrillation programmes [9,10] If CPR is not
per-* Correspondence: christoph.hanefeld@rub.de
1 Emergency Medical System of the city of Bochum, Brandwacht 1, 44894
Bochum, Germany
Full list of author information is available at the end of the article
Trang 2formed, the chance of survival decreases by 7-10% each
minute [11] In the European population, approximately,
275,000 persons would experience all-rhythm cardiac
arrest treated by the EMS with 29,000 persons surviving
to hospital discharge [3] With this in mind, public health
programmes have been initiated in different areas in the
past 10 years, focusing on CPR initiatives based on the
implementation of early defibrillation in different
institu-tions, public buildings and recreational facilities
Automated external defibrillators (AEDs) developed for
this purpose can be operated by medical laymen These
devices possess an algorithm that independently
recogn-ises a malignant dysrhythmia requiring shock delivery
and that enables shock administration" [12] In pilot
proj-ects (e.g., airports, casinos, wide-bodied aircraft and local
programmes supported by the police), survival rates of
49-74% have been achieved following the implementation
of such early defibrillation programmes [13-15] These
results have led to the initiation of further, mainly local,
programmes in highly frequented public places On an
international level, emergency medical services (EMS)
differ dramatically in terms of control-room organisation,
shared responsibilities, allocation of tasks and
distribu-tion of resources Thus, the organisadistribu-tional structures of
existing regional defibrillator programmes, most of which
are pilot projects, differ considerably Therefore,
suprana-tional comparative data of procedures, survival rates and
survival type are available to only a limited extent Two
different concepts of early defibrillation are practiced: 1)
"public access defibrillation programmes," which aim at
facilitating defibrillation among the general public; and 2)
"first responder defibrillation programmes," which
pro-vide training and equipment for professionals to
defibril-late the cardiac arrest victims they encounter during their
work In public access defibrillation programmes, AEDs
are installed in places with high volumes of people In
case of an emergency, individuals passing by (e.g., in
air-ports and central stations) are able to use the provided
AEDs in a timely manner without receiving thorough
training In first-responder defibrillation programmes,
AEDs are used by trained first responders (e.g., security
staff, police officers and accompanying personnel in
air-craft and trains) who are immediately involved in a
circu-latory arrest as an eyewitness or are the first to arrive
Both concepts are currently approved by the German
Medical Association (Bundesärtzekammer) Basic areas
under investigation include integration of the local EMS
and medical quality management [16]
In this study, we report results gathered in an early
defi-brillation project in the central Ruhr area over a period of
five years The project, called "Bochum against Sudden
Cardiac Arrest," reflects an authentic situation of a
sys-tem mainly initiated and supported by public institutions
and volunteers and implemented with the support of the local EMS
In addition to the main outcome measures "number of successful defibrillations" and "survival", we report the frequency of AED use and the timeline of AED applica-tion We also report experiences with the implementation
of the programme in Bochum, including the preceding training and an estimation of the costs of the project in relation to the number of lives saved
Methods
Bochum is a city of 380,000 inhabitants in the central Ruhr area As a city-wide programme, the "Bochum against Sudden Cardiac Arrest" initiative was imple-mented in 2003 The initiative is funded by the city of Bochum, the local EMS, various health insurance agen-cies and medical representatives from hospitals and in private practice It is also supported by numerous public and private institutions The concept was designed to facilitate dynamic improvement and enable the incorpo-ration of findings emerging in the course of the project It involves a combination of the principles of "public access" and "first-responder defibrillation programmes" Accessi-ble AEDs were successively installed in areas with high volumes of people (e.g., public buildings, businesses and event centres) in the municipal area from 2003 onwards Additionally, emergency forces and medically educated staff (e.g., fire brigades and private practices) were pro-gressively equipped with AEDs Individuals without a medical background who worked near the publicly acces-sible AEDs, in addition to emergency forces, were instructed in the use of the AEDs and were familiarised with the basics of CPR by means of training seminars A structured, one-hour AED training session was offered to small groups (maximum of eight people) Such sessions included basic knowledge of cardiovascular event recog-nition and CPR, and participation was certified and numerically recorded The training contents and local conditions were calibrated with other training seminars from, for example, the German Red Cross
The project is headed by the medical director of the EMS, and the EMS is responsible for project coordination and quality management Project-related inquiries are addressed via a central hotline The AEDs were pur-chased by individual institutions, societies and private practices with their own financial means This had an impact on the distribution pattern, as the allocation of the AEDs depended on the involved institutions rather than strategic planning Based on targeted contacting of par-ticular institutions and businesses, however, it was possi-ble to install AEDs in places considered to be high-risk (e.g., event centres and shopping centres)
The project office is informed about the use of an AED
in the municipal area via a hotline or the EMS control
Trang 3room Timely recording and medical evaluation of events
are performed by the project management in the scope of
quality management
Since April 2009, the nearest AED available to the site
of an event can be seen on a screen in the control room
Furthermore, the telephone numbers of the trained first
responders are displayed, and they can be immediately
called in case of an emergency
The reported data are a descriptive report of the
imple-mentation and clinical outcomes of an early defibrillation
programme in a German urban area over five years
Results
Following the initiation of the programme at the end of
2003, 155 AEDs were successively put into operation in
the Bochum municipal area up to the present day (for the
distribution, see Fig 1), and 6,294 first responders were
trained
In total, 12 AED administrations after circulatory
col-lapse were recorded and analysed during the period of
data collection (08/2004 - 08/2009) (see Fig 1).
Ten AED administrations were preceded by the
observed collapse of the subjects, whereas two
adminis-trations were preceded by an unobserved collapse In all
12 cases, the AEDs were used prior to the arrival of the
emergency physician who was called to ensure further
medical treatment of the patient
There were seven cases of VF, four cases of
non-malig-nant dysrhythmia and one case of asystole (see Table 1).
The patients who suffered non-malignant heart rhythms
were responsive at the time of EMS arrival
The two patients with VF who could be discharged
from the hospital survived without any neurological
dam-age (see Table 2) In both cases, an AED was directly
available at the emergency site (< 100 metres); it was used
by laymen onsite, and AED shock delivery led to
success-ful conversion into a palpable rhythm In the case of the
other five patients with VF, an AED was not directly
avail-able at the emergency site but was retrieved by a first
responder (in one case, the first responder was a trained
passerby, and in four cases, the AED was used by alerted firemen) Thus, the AED could only be used after a time delay of 4-6 minutes In these cases, no conversion into a palpable rhythm could be achieved In two cases, the shock was administered after 149 and 190 seconds, and the automated speech announcement was ignored, despite a recommendation for shock delivery It is pre-sumable that in these cases, the users were reluctant to deliver the shock In the four cases in which anamnestic data about the circulatory collapse were available and non-malignant dysrhythmia could be demonstrated, the AED rightly recognised that shock delivery was not required
The mean time between turning on the units and appli-cation of the electrodes to the patient was 39 seconds (±
20 SD); 54 seconds elapsed (± 20 sec.) until the AED rec-ommendation of "shock delivery" was displayed, and 96 seconds (± 20 sec.) elapsed until shock administration Generally, proper function of the AEDs could be demon-strated in all cases The unit protocols showed the proper technical procedure during use and the units gave auto-mated speech announcements conforming to the guide-lines
In the course of the project, two lives may have been saved due to AED use leading to defibrillation The esti-mated overall costs of the project are 651,380 € (see Table 3); however, the small numbers and study design do not allow proper estimation of the costs per saved life or qual-ity-adjusted life years (QALYs)
Discussion
The present study reports five-year results of the first city-wide early defibrillation project in a German city Our observation of proper AED function in all cases is consistent with other reports that modern AEDs from different providers are reliable in clinical use and enable quick, valid rhythm analysis and shock delivery if required [17,18] Artefacts in AED recordings previously reported by others were not observed here [19] The times between turning on the unit and announcement of shock delivery (mean value, 54 sec) and shock adminis-tration itself (mean value, 96 sec) are within the time ranges reported by other authors [20]
Every delay decreases the chance of successful defibril-lation, as shown in our study in which a delay of 4-6 min-utes until the arrival of firemen led to unsuccessful resuscitation in two cases requiring defibrillation This has been confirmed by other authors; in the British National Defibrillator Programme, the installation of AEDs for public access defibrillation was clearly superior
to the first responder strategy with transported AEDs [21] In a study conducted by Cappucci et al in the Piaz-enza region of Italy, the time lapse until the arrival of first responders in the vicinity and EMS was 4.8 min (± 1.2
Figure 1 AED Sites and Users, Total Number of AEDs Placed = 155.
Trang 4min) and 6.2 min (± 2.3 min), respectively [22] Generally,
it must be considered that only about 1/3 of all sudden
cardiac/circulatory arrests occur in public; the vast
majority of these events occur in domestic environments
[23] The total number of 12 patients in this project
seems relatively small considering that the incidence of
treated primary arrests ranges from 37-100/100,000
annually according to a review by Chugh et al [24] This
was confirmed by the ANPAD programme in which very
few patients were reached, despite a relatively high
num-ber of installed devices [18] Public access defibrillation is
a highly effective strategy for patients with sudden
car-diac arrest (SCA) in public places where AEDs are
installed as shown in the British National Defibrillator
Programme [20] In that study, hospital discharge after
SCA was achieved in over one-quarter of patients after
the use of permanently installed AEDs Deployment of
AEDs reduces the time of the
Call-to-the-First-AED-Prompt [25] In the Public-Access Defibrillation Trial, the
use of AEDs in communities was associated with a near
doubling of survival after out-of-hospital cardiac arrest
These reports reinforce the importance of strategically
expanding community-based AED programmes [26]
With regard to the strategic planning of AED placement,
the recommendations of the European Resuscitation
Council (ERC) differ from those of the American Heart Association (AHA); the ERC recommends AED installa-tion in places where a cardiac/circulatory arrest is to be expected within two years, whereas the AHA recom-mends installation in places where a cardiac/circulatory arrest is to be expected within five years [27,28] Earlier studies have suggested airports, highly frequented shop-ping centres, major businesses, sports clubs and recre-ational facilities [29,30] In the literature, risk evaluation with regard to the relationship between use (including cost) and probable benefit has been recommended for the strategic planning of AED distribution [31] According to
a Danish study, high coverage of 10.6% of the city area was necessary to cover 66.8% of all cardiac arrests, whereas coverage of 1.2% only led to 10.6% of SCAs being reached [32] Therefore, the AHA recommendations seem to be superior to the ERC guidelines
Compared with other cities, e.g., Warsaw, the ratio of AEDs in Bochum is relatively high (one AED per 14,706 people in Warsaw vs one per 2,451 citizens in Bochum) [33]
In Bochum, however, the current allocation of AEDs is still not comprehensive Important sites for AED
place-Table 1: Clinical outcome depending on underlying rhythm disturbance and type of resuscitation
documented by AED
to shock delivery
non-malignant
dysrhythmia
SR (bradycardia) SR - discharged from hospital No shock recommended
SR SR 1 cycle discharged from hospital No shock recommended
AV junctional escape rhythm
idem - discharged from hospital No shock recommended
AV junctional escape rhythm
idem - discharged from hospital No shock recommended
Table 2: AED use: frequency and outcome
Total AED use 12 Successful defibrillations Survived
Table 3: Approximate estimation of costs: 5-year AED project
Hotline, surveillance, evaluation (labour costs)
40.000 € × 5 years 200.000 €
Trang 5ment might have been omitted, and this could explain the
relatively small number of 12 AED administrations
dur-ing the project The estimated costs of the project of
more than 650,000 € for two saved lives within a five-year
period is consistent with other investigations, showing
that unguided placement is expensive and requires
approximately threefold greater cost than strategically
planned placement [34] Training and equipping lay
vol-unteers to use defibrillators, however, seems to be
cost-effective compared to CPR training alone with regard to
QALYs [28]
In the literature, it has been reported that the use of
AEDs involves a high readiness to perform resuscitation
[35-37] According to the present data, resuscitation
measures were performed by the AED user onsite for at
least six of the eight patients who presented with
pulse-less cardiac/circulatory arrest Clearly, the automated
speech announcements of the unit were followed
ade-quately with respect to the performance of
cardiopulmo-nary resuscitation This experience has been confirmed
by observations made by other authors [38,35]
The present study has several limitations At the
begin-ning, due to its nature, the Bochum project was not based
on a prospective study design with dedicated planning
and a clear strategic determination of the number of
AEDs, AED locations and the groups of persons involved
and to be trained It was designed as an initiative
sup-ported by different institutions with the potential for
dynamic growth Therefore, this study offers
observa-tional data from experiences during the implementation
of a dynamic early defibrillation system project in a
Ger-man city
Due to the emergency medical and administrative
structure in Germany, the EMS control room was
informed about only a fraction of sudden deaths Thus,
valid data were not available regarding the frequency of
sudden deaths, and representative data could not be
col-lected in the scope of this study with regard to the time
span between the occurrence of a cardiac/circulatory
arrest and shock delivery Although the time of alerting
the EMS could be tracked, it was not possible to
defini-tively conclude the timeline of the actual emergency
events In addition, the EMS trips reflected only a
frac-tion of the total events Furthermore, inaccurate data
with regard to time were determined based on the AEDs
used For future analyses, the use of radio-controlled
clocks in the AEDs should be considered for more
accu-rate time analyses
It must be mentioned that the training consisted mainly
of one-time sessions, and follow-up training was only
offered to some extent There were no evaluations, so no
conclusions can be drawn about the actual skill level of
the involved individuals In the future, follow-up training
and training for an additional 500 persons are planned
Despite these limitations, important conclusions can be drawn from this study for future projects The combina-tion of the "first responder" and "public access defibrilla-tion programme" concepts appears to be reasonable According to our experience, the training of a large num-ber of first responders seems to be feasible within the given EMS structure and in other urban German areas The coordination and high-quality management of such city-wide initiatives by a project office such as that affili-ated with the EMS seems to be reasonable The project office in this study performed 470 consultations via the hotline number during the observation period; therefore, the installation of a hotline seems to have been appropri-ate
The relatively low number of 12 cardiac arrests within a period of 5 five years could be partly explained by the lack
of comprehensive placement of AEDs in high-risk areas The identification and equipping of high-public-access places according to the AHA recommendations (see above) is essential and will be realised with 35 additional AEDs within the next two years
Since April 2009, information about the AED locations has been available from a central computer, and it has been possible to immediately alert first responders near the emergency site Future analysis of the provided data and additional equipment for first responders (especially
in the scope of major events) is expected to enable further improvements of this dynamic, continuing learning sys-tem
It would be desirable to conduct large-scale prospective studies on city-wide early defibrillation projects in large cities to further improve the outcomes and cost-effective-ness of early defibrillation programmes
Competing interests
The authors declare they have no competing interests.
Author Details
Emergency Medical System of the city of Bochum, Brandwacht 1, 44894 Bochum, Germany
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Received: 15 February 2010 Accepted: 15 June 2010 Published: 15 June 2010
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© 2010 Hanefeld; licensee BioMed Central Ltd
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doi: 10.1186/1757-7241-18-31
Cite this article as: Hanefeld, A first city-wide early defibrillation project in a
German city: 5-year results of the Bochum against sudden cardiac arrest
study Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
2010, 18:31